Nursing Investigation Results -

Pennsylvania Department of Health
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Inspection Results For:

There are  44 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey completed on June 6, 2022, it was determined that Health Center at the Hill at Whitemarsh, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.




 Plan of Correction:


483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:

Based on group interview, observations and interviews with staff, it was determined that the facility failed to display proper contact information, including the appropriate phone number for filing complaints concerning any suspected violation of state or federal nursing facility regulations for two of two nursing units. (Second Floor and Third Floor)

Findings include:

During a group interview with Resident R3, Resident R6, Resident R41 and Resident R94 on June 3, 2022, at approximately 10:15 a.m. Resident R41 indicated that he did not know how to contact the Pennsylvania Department of Health if he had a complaint. Resident R3 agreed and said he also did not know where to find this information. When asked if they know how to contact the Pennsylvania Department of Health, Residents R6 and R94 shook their heads no.

Observations of both nursing floors after the group meeting on June 6, 2022, at approximately 10:45 a.m. revealed that the State Department of Health contact information was not posted as required.

Interview with the Nursing Home Administrator, and Employee E9, Quality Assurance Coordinator, on June 6, 2022, at approximately 9:20 a.m. confirmed that the contact information was not posted as required.

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(1)(3) (e)(1) Management

28 Pa. Code 201.29(i) Resident rights








 Plan of Correction - To be completed: 06/11/2022

- Immediate action was taken upon inspection of the second and third floor, the Grievance Officer, posted the proper contact information, including the appropriate phone number for filing complaints concerning any suspected violation of state or federal nursing facility regulations.
- Residents and/or family RP's will be notified and educated as to where the information is posted. Monthly the Grievance Office will attend Resident Council and include the information in the resident care conference. In addition, the information is included in the Admission Packet for new Admissions and will be discussed at their care conference.
- An audit will be conducted by SS Director or designee weekly for x6 weeks to ensure notification signage indicating the name of the facility Grievance Officer remains posted, and a monthly report will be submitted to QAPI to ensure compliance.

483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations and resident and staff interviews, it was determined that the facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on both nursing floors. (Second Floor and Third Floor)

Findings include:

During a group interview conducted on June 3, 2022, at 10:00 a.m. with four alert and oriented residents (Residents R41, R3, R6 and R94), the residents stated that they were not aware of how to file a grievance with the facility. The residents were also unaware of who was the Grievance Official in the facility. All four residents in attendance stated that they were unaware of any postings in the facility, which was comprised of two nursing floors, regarding how to file a grievance.

Observations during a tour of the Second Floor and Third Floor and bulletin boards throughout the facility, conducted at approximately on June 3, 2022 11:00 a.m., after the group interview, revealed no posting about the Grievance Procedure, or who was the Grievance Official, or a box to place a grievance anonymously. There were no postings on the Second or Third floors related to how to file a grievance.

During an interview with Employee E5, Nursing Home Administrator(NHA), and Employee E9, QA Coordinator, on June 6, 2022, at approximately 9:20 a.m., the NHA acknowledged that the facility failed to post the grievance process including the Grievance Official contact information in a prominent location on both nursing floors of the facility as required.


28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 201.29(c)(d)(e) Resident rights






 Plan of Correction - To be completed: 06/11/2022

- Immediate action was taken, upon inspection of the second and third floor, the Grievance Officer, posted the proper contact information, including the appropriate phone number for filing complaints concerning any suspected violation of state or federal nursing facility regulations.
- Residents, staff, and/or family RP's will be educated as to where the information is posted and to file any concern or complaint. Monthly the Grievance Office/SS Director/designee will attend Resident Council and include the information in the resident care conference. For Short Term Residents/Admissions the information is included in the Admission Packet and will be reviewed in their care conference.
- A random audit of 5 residents per week x6 weeks will be conducted by SS Director to ensure the process is successful and residents can state who grievance office is in the facility. Audit results will be presented in QAPI monthly meeting for review to ensure 100% compliance

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on closed record review and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for one of three closed records reviewed (Residents R44).

Findings include:

Review of Resident R44's clinical record revealed that resident was admitted to the facility on March 11, 2022 with diagnoses of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and cerebral infarction (stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood).

Review of nursing documentation revealed that on April 1, 2022, the resident was transported to the emergency room via 911- Emergency Medical Services, and that the resident's wife and physician were notified.

Interview on June 6, 2022, with the Director of Nursing confirmed that the Admissions Director, who normally notifies the Office of the State Long-Term Care Ombudsman for emergency transfers to the hospital, had not sent these notifications for the past six months.

The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges.


28 Pa. Code 201.14(a) Responsibility of licensee




 Plan of Correction - To be completed: 07/25/2022

- Immediate action was taken, Admissions Coordinator notified the Office of the State Long-Term Care Ombudsman for facility-initiated emergency transfers and discharges process.
- Admissions Coordinator/designee has generated an ongoing list of all facility-indicated emergency transfers and discharges. This list will be updated weekly and will be submitted monthly to the Office of the State Long-Term Care Ombudsman per state regulations.
- An audit will be conducted by the Admissions Coordinator/designee monthly x8 weeks. Audits will be presented in QAPI to ensure 100% compliance


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port